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Inspectors wroteBased on medical record review, staff interviews, and facility policy review, the facility failed to notify the physician of a resident's change in condition. This affected one (#10) of three residents reviewed for change in condition. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a clean and home-like environment. This affected two (#13 and #18) of eight residents review for environment. The facility census was 81.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure timely drainage of urinary catheter bags. This affected one (#12) of four residents reviewed for urinary catheters.

Inspectors wroteBased on observation medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure respiratory supplies were stored and dated in a safe manner and failed to ensure a resident's need for supplemental oxygen was provided in a timely and sufficient manner. This affected two (#13 and #57) of five residents reviewed for oxygen. The facility census was 81.

Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure documentation in the electronic health record was complete and accurate. This affected two (#10 and #11) of eight residents reviewed for documentation. The facility census was 81.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure proper signage was in place for a resident on enhanced barrier precautions and failed to ensure urinary catheter bags were maintained in a manner to prevent infection. This affected two (#58 and #59) of four residents reviewed for infection control practices.

Inspectors wroteBased on observation, record review, staff interview and policy review, the facility failed to ensure complete proper hand hygiene during a dressing change. This directly affected one (Resident #8) of three residents reviewed for wound care. The facility census was 83.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure resident medications were prepared per professional standard. This affected on four Residents (#77, #78, #79, and #80) of four observed. The facility census was 82. Findings Include:Observation on 11/13/25 at 8:53 A.M. to 9:03 A.M. revealed Licensed Practical Nurse (LPN) #134 had three medication cups of unidentified pills on top of medication cart. LPN #134 picked up loose loose pills that were laying on top of medication cart using her bare hand, placed them in a clear sleeve and proceeded to crushed the pills. LPN #134 then was observed to placed the unidentified crushed pills in a fourth medication cup. LPN #134 placed three medication cups of unidentified pills into the medication cart. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure medications were not left unattended. This affected one Resident (#87). The facility census was 82. Observation on 11/13/25 at 11:19 A.M. with Licensed Practical Nurse (LPN) #142 revealed Resident #87's medications (Albuterol Sulfate HFA (bronchodilator) aerosol inhaler, Astepro (antihistamine) nasal spray, Basaglar Kwikpen u-100 Insulin pen (long acting Insulin), Aspart Insulin pen u-100 (quick acting Insulin), and Symbicort HFA (corticosteroid) aerosol inhaler) were laying on top of medication cart unattended for four minutes. During the time the medications were on the medication cart unattended one family member, four residents and two staff members walked by medication cart. [...]

Inspectors wroteBased on observation and interview, the facility failed ensure proper handling of medication was used when preparing medication. This affected one Resident (#79) during medication pass. The facility census was 82. Observation on 11/13/25 at 8:53 A.M. with Licensed Practical Nurse (LPN) #134 the nurse was observed to picked up an unidentified number of pills for Resident #79 off of top medication cart with her bare hand, place the medications in a clear sleeve, and crush the medications to be administered for Resident #79. LPN #134 then placed pudding into the crushed medication cup and walked to Resident #79 in the common area, close to the nurse ' s station and administered the medication. Interview on 11/13/25 at 8:57 A.M. with LPN #134 it was verified she did not place Resident #79's pills in a medication cup but placed them on top of the medication cart on purpose. [...]

Inspectors wroteBased on staff interview, observation, record review, and policy review, the facility failed to notify a resident representative of a new skin condition. This affected one (#15) of five residents reviewed for a change in condition. The facility census was 73. Review of the medical record for Resident #15 revealed an admission date of 01/11/22 with diagnoses of dementia, anxiety, anemia, and Type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, completed 06/06/25, revealed Resident #15 had impaired cognition and required substantial/maximal assistance for bed mobility and was dependent for transfers. Review of Resident #15's electronic medical record (EMR) from 06/01/25 through 07/17/25 at 9:30 A.M. revealed no documentation regarding a bruise or new skin concern to Resident #15's face or neck. [...]

Inspectors wroteBased on staff interview, record review, observation, and policy review, the facility failed to ensure timely assessments of a new skin condition. This affected one (#15) of five residents reviewed for change in condition. The facility census was 73.

Inspectors wroteBased on observation, staff interview, and review of facility policies, the facility failed to ensure food was labeled and properly refrigerated, the kitchen was maintained in a sanitary manner, and food was not handled with contaminated gloves. This had the potential to affect all residents who consume food from the kitchen. The facility census was 81.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure medications were not prepared and stored in medication cart prior administration. This affected four (#05, #19, #42, #65) out of the fourteen residents that resided on Legacy Hall. Additionally, the facility failed to ensure an opened insulin pen was dated upon first use and was not expired. This affected one (#09) out of three resident insulin pens observed in the Legacy Hall medication cart. The facility census was 81.

Inspectors wroteBased on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure call lights were in reach of residents. This affected four residents (#15, #14, #57 and #4) of nine residents reviewed for call lights. The facility census was 81.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident beds were maintained in a safe condition. This affected one resident (#53) of nine reviewed for physical environment concerns. The facility census was 81.

Inspectors wroteBased medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were free from any physical restraints. This affected two (#28 and #73) out of two residents reviewed for restraints. The facility census was 81.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the care plan was updated timely to include the development of a pressure ulcer for one (#4) out two residents reviewed for pressure ulcers. The facility census was 81.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to follow physician orders to apply washcloths to the hands of one (#53) of four residents reviewed for skin conditions. The facility census was 81.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to accurately assess a pressure ulcer, failed to complete an assessment of a pressure ulcer when identified, and failed to obtain a treatment for a pressure ulcer. This affected two (#38 and #4) out of three residents reviewed for pressure ulcers. The current census is 81.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of facility policy, the facility failed to document a fall in the medical record, complete post fall assessments, and investigate a fall in a timely manner. This affected one (#54) of three residents reviewed for falls. The facility census was 81.

Inspectors wroteBased on observation, record review, resident interview, staff interview and policy review, the facility failed to ensure a physician order was present to administer oxygen. This affected one (#13) of three residents viewed for oxygen. The facility census was 81.

Inspectors wroteBased on record review, review of the facility policy, and staff interview, the facility failed to ensure the physician responded to pharmacy recommendations timely and included a reason for the denial of gradual dose reductions. This affected one (#48) out of five residents reviewed for unnecessary medications. The facility census was 81.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure medication was administered as ordered by a physician. This affected one (#386) of five residents reviewed for unnecessary medications. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and resident interview, the facility failed to provide a clean and comfortable environment. This affected one (#48) resident and has the potential to affect all resident residing in the facility. The current census is 81.

Inspectors wroteBased on employee file review, staff interview, and review of facility policy, the facility failed to ensure certified nursing assistants (CNAs) had evaluations completed every 12 months. This had the potential to affect all residents residing in the facility. The facility census was 81.

Inspectors wroteBased on review of facility infection control records, staff interviews, review of staff schedules, review of time punch records, review of electronic mail (e-mail) correspondence, review of facility policies and procedures, review of the Center for Disease Control and Prevention CDC) guidance, and review of Ohio Department of Health's (ODH) guidance for reporting infectious diseases, the facility failed to develop and implement effective infection control practices including written policies and procedures which included when and to who potentially communicable diseases should be reported, and failed to ensure the local health department was notified in a timely manner of a facility gastrointestinal illness outbreak. [...]

Inspectors wroteBased on dining observations and staff interview the facility failed to treat 13 residents (#03, #06, #07,#36, #37, #42, #45, #51,#56, #59, #61, #333, and #434) eating in the restorative dining room with dignity during the meal. The facility census was 78.

Inspectors wroteBased on dining observations and staff interview the facility failed to ensure there was adequate space in the restorative dining room for 13 residents (#03, #06, #07,#36, #37, #42, #45, #51, #56, #59, #61,#333, and #434) requiring extensive assistance with eating. The facility census was 78.

Inspectors wroteBased on medical record review , observation, resident and staff interviews and facility policy review the facility failed to provide one resident (#36) of one resident reviewed with an adaptive call light. The facility census was 78.

Inspectors wroteBased on medical record review, resident and facility staff interviews, the facility failed to honor choices of two of 12 sampled residents (Resident #32 and Resident #75), regarding showers. The facility census was 78.

Inspectors wroteBased on observations, medical record reviews, therapy, family and staff interviews, the facility failed to maintain ambulation for one (Resident #55) of one residents reviewed for activities of daily living (ADL) decline, in a total sample of 18 residents. The facility census was 78.

Inspectors wroteBased on observations, medical record review and staff interviews, the facility failed to prevent a delay in treatment of surgical wound and suture (stitches) removal for one (Resident #75) of two residents reviewed for hospitalization. The facility census was 78.

Inspectors wroteBased on record review, staff and resident interview, and observations the facility failed to ensure one resident ( #43) of 18 sampled residents received her hearing aids on a consistent basis. The facility census is 78. Findings Include: Review of the medical record for Resident #43 revealed an admission date of 12/01/21. Diagnoses included, unspecified dementia without behavioral disturbance, anxiety disorder, hypokalemia, essential hypertension, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/22, revealed she was moderate cognitive impairment. The assessment, section B (Hearing) revealed moderate difficulty - speaker has to increase volume and speak distinctly, and indicated hearing appliance used. There were no behaviors indicated. [...]

Inspectors wroteBased on medical record review, review of pharmacy recommendations and interview the facility failed to timely respond to pharmacy recommendations. This affected one resident (#05) of five residents reviewed for unnecessary medications. The facility census was 78.

Inspectors wroteBased on medical record review,observations, family and staff interviews the facility failed to ensure a clean sanitary environment was maintained for one resident (#07) in a total sample of 18 residents. The facility census was 78.

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to maintain infection control in the laundry room. This affected 90 of 90 residents residing in the facility who used the facility laundry.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure proper disposal of medications. This had the potential to affect six (#12, #19, #50, #62, #83 and #84) of seven residents near the medication cart who were independently mobile with impaired cognition. The facility census was 90.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure a medication cart was locked. This had the potential to affect seven (#29, #41, #49, #67, #71, #81 and #89) of 31 residents the facility identified as independently mobile with impaired cognition residing in the three hallways near the medication cart. The facility census was 90.

Inspectors wroteBased on record review, family interview, staff interview and policy review, the facility failed to clarify the physician's order on a DNR identification form. This affected one (#85) of two resident reviewed for advanced directives. The facility identified 25 residents as full code status. The facility census was 90.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to provide the bed hold policy to Resident #64 and Resident #79. This affected two (#64 and #79) of two residents reviewed for hospital discharges. The facility census was 90.

Inspectors wroteBased on record review, staff interviews and policy review, the facility failed to ensure a resident received assistance with showers as scheduled. This affected one (#42) of one residents reviewed for showers. The facility census was 90.

Inspectors wroteBased on record review, observation, resident interview, and staff interview the facility failed to monitor an open wound on the resident's right shin. This affected one (Resident #90) of six residents reviewed for skin conditions. The facility failed to ensure a bowel management program was initiated a resident. This affected one (Resident #85) of one resident reviewed for bowel management. The facility census was 90.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident was seen by the physician for the initial visit in the facility. This affected one (Resident #50) of three resident reviewed for physician visits. The facility census was 90.